A brief practical review of anesthesia management in ischemic heart disease patients.

1. Management Of Anesthesia In
Ischemic Hear Disease Patients
(brief practical review)
Reza Aminnejad; M.D.
Anesthesiologist.

3. In The Name of God

4. Ischemic Heart Disease

5. Management of anesthesia in
patients with known or
suspected IHD undergoing non
cardiac surgery

6. Intraoperative Management
(Basic Challenges)
 Prevent myocardial ischemia by optimizing
myocardial oxygen supply and reducing
myocardial oxygen demand
 Monitor for ischemia and treat ischemia if
it develops.

7. Intraoperative Events That Influence the
Balance Between Myocardial Oxygen Delivery
and Myocardial Oxygen Requirements
 Decreased O2 Delivery (Decreased
coronary blood flow, Tachycardia, Diastolic
hypotension, Hypocapnia (coronary artery
vasoconstriction), Coronary artery spasm, Decreased
oxygen content, Anemia, Arterial hypoxemia, Shift of the
oxyhemoglobin dissociation curve to the left)
 Increased O2
Requirements (Sympathetic nervous system
stimulation, Tachycardia, Hypertension, Increased
myocardial contractility, Increased afterload, Increased
preload)

8. Maintenance of the balance between
myocardial oxygen supply and
demand is more important than the
specific anesthetic technique or drugs
selected to produce anesthesia and
muscle relaxation.

9. A common recommendation is to keep
the heart rate and blood pressure within
20% of the normal awake value.

10. Induction of Anesthesia
 Intravenous induction drug is preferred.
 Short-duration direct laryngoscopy (≤15
seconds) is considered.
 Laryngotracheal lidocaine, intravenous
lidocaine, esmolol, and fentanyl have all
been shown to be useful for blunting the
increase in heart rate evoked by
tracheal intubation.

11. Maintenance of Anesthesia
 In patients with normal LV function volatile
anesthetic with or without N2O or N2O– opioid
technique with the addition of a volatile anesthetic
to treat any undesirable increases in BP that
accompany painful surgical stimulation is
recommended.
 In patients with severely impaired LV function
opioids may be selected. A benzodiazepine may
be needed for amnesia but the addition of N2O or
a volatile anesthetic may be associated with
myocardial depression.
 It seems prudent to maintain intraoperative heart
rate at less than 80 bpm.

12. Choice of Muscle Relaxant
 Vecuronium, rocuronium &
cisatracurium have minimal or no effect
on HR & SBP.
 For reversal of neuromuscular blockade
with an anticholinesterase /
anticholinergic drug combination,
glycopyrrolate, which has much less
chronotropic effect, is better than
Atropine.

13. Monitoring
 ECG
 PCWP
 TEE

14. Relationship of Electrocardiogram
Leads to Areas of Myocardial Ischemia
 Leads II, III & aVF→ RCA→ RA, RV, SA
node, Inferior aspect of LV, AV node
 Leads I & aVL→ CCA→ Lateral aspect of
LV
 Leads V3–V5→ LAD→ Anterolateral
aspect of LV

15. Pulmonary Artery Catheter
 Intraoperative myocardial ischemia can manifest as
an acute increase in pulmonary artery occlusion
pressure due to changes in left ventricular
compliance and systolic performance.
 A pulmonary artery catheter is not a sensitive
monitor for detecting small ischemic insults but it
can be more useful as a guide in the treatment
of myocardial dysfunction.
 Use of a pulmonary artery catheter has not been
shown to be associated with improved outcomes.
 CVP and pulmonary artery occlusion pressure
correlate in patients with ischemic heart disease
when the ejection fraction is greater than 50% .

16. TEE (Trans Esophageal Echocardiography)
 Regional wall motion abnormalities
occur before ECG changes occur.
 The limitations of TEE include its cost,
the need for extensive training in
interpretation, and the fact that it cannot
be inserted until after induction of
anesthesia.

17. Intraoperative Management of
Myocardial Ischemia
 Treatment of myocardial ischemia should be
instituted when there are 1-mm ST-segment
changes on the ECG.
 Prompt, aggressive pharmacologic treatment of
changes in heart rate and/or blood pressure
is indicated.
 Consider esmolol for persistent increas in HR &
nitroglycerin for normal or modestly elevated BP.
 Hypotension is treated with sympathomimetic
drugs to restore coronary perfusion pressure.
 In an unstable hemodynamic situation, circulatory
support with inotropes or an intra-aortic
balloon pump may be necessary.

18. Postoperative Management
 Prevent intraoperative hypothermia, pain,
hypoxemia, hypercarbia, sepsis, and
hemorrhage.
 Continue β-blockers throughout the
perioperative period.
 Maintain intravascular volume and an
adequate hemoglobin concentration.
 patients with IHD can become ischemic
during emergence from anesthesia and/or
weaning with an increased heart rate and
blood pressure.